Enhancing Operational Efficiencies in Medical Transaction Processing
08 July 2024
Posted by Admin
Executive Summary
CrosLinks, a solutions and services company, collaborated with a leading
nationwide diagnostics laboratory in the United States to enhance the efficiency
of medical transaction processes, particularly in insurance verification, patient
engagement, prior authorization, and medical billing. The current inefficiencies in
transaction processing are primarily due to complex billing procedures, insurance
interactions, and varied patient demographics.
This case study focuses on improving the operational efficiency of the prior
authorization filing process for genetic tests. It outlines strategic initiatives
such as process consolidation, platform setup, and continuous monitoring to enhance
throughput and ensure the timely completion of transactions. The analysis identifies
key factors contributing to inefficiencies and proposes targeted steps to improve
performance and ensure the successful completion of the prior authorization process.
Introduction
XYZ Corp is a leading company in genetic testing, performing millions
of tests annually in the fields of oncology, women’s health, and organ health.
With a network of clinics and centralized testing centers across the United States,
XYZ Corp directly engages with patients and healthcare providers to collect samples,
perform tests, and manage billing with insurance companies.
Due to rapid growth, XYZ Corp has faced challenges in maintaining a high
completion rate for approved authorization claims due to varying filing deadlines
and stringent documentation requirements set by insurance providers.
This case study explores the root causes of these challenges and recommends solutions
to streamline the prior authorization process.
Problem Statement
XYZ Corp operates a billing model in which the company directly bills insurance
providers on behalf of patients for completed genetic tests. The typical process
involves:
1. Obtaining prior authorization from the insurance provider.
2. Collecting samples from patient and performing tests.
3. Submitting test results and generating bills for the tests.
4. Sending the bills to the insurance provider.
However, due to the nature of XYZ Corp’s operations, insurance interactions
typically begin after tests are completed. Although insurance providers allow retroactive
prior authorization requests, these must be filed within a specific time-frame. Missing this
filing window results in claim denials and financial losses for XYZ Corp.
Key factors contributing to these issues include untimely filing,
inaccurate patient information, improper documentation, and delayed
follow-up with claims. The requirements and processes vary significantly
across insurance providers, complicating the submission process and increasing
the likelihood of missed filing deadlines.
Methodology
The study involved collecting data from multiple insurance
providers regarding the time and steps required to process prior
authorization requests. Insurance providers were grouped based on test types,
processing methods, and request types.
Standard processing templates were created, and these templates were
analyzed against actual workflows to identify redundancies and ensure
compliance with mandated steps.
Based on these findings, a comprehensive application system was
developed to manage claims according to insurance-specific filing methodologies,
parameters, rules and deadlines.
Analysis
The analysis revealed several key factors contributing to inefficiencies:
• Lack of Timely Filing:
Failure to submit requests within the allowed retro window.
• Documentation Requirements:
Incomplete or missing required documentation.
• Completeness of Claims:
Inadequate medical necessity documentation and other supporting documents.
• Patient Engagement:
Challenges in obtaining complete and accurate insurance data.
• Insurance Verification:
Issues with validating patient information with insurers.
• Claim Monitoring:
Insufficient tracking and follow-up on submitted claims.
Solutions and Recommendations
To address these issues, the following strategies were implemented:
• Application System Development:
Introduced a system that integrates insurance-specific parameters, automates case assignments, and manages follow-up processes.
• Automated Document Retrieval:
Developed automated document retrieval and assignment based on insurance requirements, ensuring that all medical necessity documents are included in submissions.
• Workflow-Based Processing:
Created templates for processing claims tailored to each insurance provider, streamlining the workflow and reducing processing time.
• Shared Resource Pool:
Established a cross-trained workforce capable of handling claims for all insurance providers, improving resource utilization and efficiency.
Process Improvements:
• Insurance Provider Setup:
Grouped providers based on processing parameters such as claim type, processing method, and documentation needs. Established processing windows for timely submission.
• Claim Processing:
Automated processing templates, portal submissions, and document retrieval, leading to standardized case handling across agents.
• Case Assignment:
Designed a workflow system to assign cases based on urgency and insurance parameters, ensuring timely filing and balanced workloads.
• Monitoring Tools:
Implemented dashboards and tracking tools for monitoring claim processing, enhancing operational visibility and agent performance.
• Throughput Handling:
Distributed case flow among agents to optimize workload management and resource allocation.
Operational Throughput Improvements:
Further Recommendations
• Transaction-Based Billing:
Transition to a transaction-based billing model, allowing resource optimization and cost savings.
• Tiered Pricing Model:
Establish tiered pricing for smaller testing centers, making the service accessible and beneficial.
• Cross-Training and Shared Resource Pool:
Train all employees to handle multiple insurance providers to maximize workforce flexibility.
• Workload Balancing:
Use distributed workflow processing to handle peak and off-peak workload fluctuations efficiently.
• Incentivize High Performance:
Introduce a transaction-based bonus program to encourage high throughput and efficiency among employees.
Conclusion
The strategic initiatives implemented have significantly improved operational efficiency and transaction processing at XYZ Corp.
Key outcomes include:
• Increased Throughput:
A 50% increase in transactions processed per day.
• Reduced Processing Time:
Processing times reduced by 30-70%, depending on the insurance provider.
• Consistent Claim Filing:
Enhanced accuracy with no missed filing windows or documentation errors.
• New Billing Models:
Introduction of transaction-based pricing and performance incentives.
By addressing the inefficiencies in the prior authorization process, XYZ Corp has achieved higher productivity, reduced claim denials, and optimized resource utilization.
References
• Time Study of Claim Processing by Insurance Providers
• Operational Templates by Insurance Provider
• Insurance Provider Guidelines
